Confused about when to start meds

Oct 5, 2009

I know current guidelines say to start meds at CD-4 350. Newer research is saying it should be started at 500. I've been told the main reason to wait is put off side-effects, but mainly due to resistance.

I've read most people will develop resistance within a few years. Then I read where some docs start patients on meds right away with CD-4 readings of 800, 900, or higher. Are they going to run into resistance problems much sooner?

I was reading about the conference in South Africa where they said there's not as many new drugs in the pipeline as in the past. If there is not a cure found, are we going to run out of drugs to use? We hear this same talk about antibiotics, but most of us just pass that off thinking they'll come up with new antibiotics when those stop working.

It is all just so confusing. I was reading where if you're not on meds because your numbers are good, you could be having immune system inflamation. I guess because your VL isn't suppressed, your immune system is in a hyper state all the time--which I guess is not good.

Thanks for all you guys do!

Response from Dr. McGowan

Thanks for your question. You have hit on one of the hottest debates right now in HIV treatment circles.

Treatment of HIV is unique in a couple of ways: 1) It is a persistent infection that (at this point) cannot be eliminated from the body, so treatment will be lifelong; 2) We have very active treatment that can fully suppress the virus indefinitely but; 3) We do not treat everybody because of the possibility of long-term side effects and that people may tire of taking their meds and when they slack off the virus may develop resistance to treatment.

Many of the downsides to treatment have been addressed by newer meds that cause fewer long-term side effects and are easier to take (once a day with fewer pills). Also studies (like the SMART trial) have shown that being on treatment gives an advantage in preventing death and disease of the kidneys, liver and heart. This is especially true if the CD4 count is below 350.

As you mention there are new studies that show some benefits for starting meds at higher CD4 counts. These studies do not carry the weight of a study like the SMART trial and not all studies show that starting meds above 350 is better. That is the area of debate.

Most docs believe that it is bad to allow virus to grow unchecked. Some of the damage to the body may come not from the virus directly, but from the inflammation (called immune activation) that the virus causes. The immune system tries to contain the virus which is what leads to the inflammation. When virus is suppressed, the immune activation slowly decreases. What is not known now is the best time to interrupt this process...when does the balance tip in favor of treatment in this progressive imbalance in the immune system? There is a planned study called START which will help to address this question, but the results will not be available for a few years.

Lastly, although the development of new classes of drugs may slow down for the next few years, we have more than enough meds now to treat the vast majority of people with HIV. The key for long-term success and avoidance of resistance is to remain adherent with the meds and not to get fatigued and start missing doses, even after many years. If the virus is undetectable and a person does not miss doses, there is no reason to expect the meds to ever stop working.

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